Total PArenteral Nutrition Flashcards
starting with info from review slides
What is included in the daily routine monitoring of a client on TPN?
- TPN Flow rate checked hourly
- careful I&O’s, assessing lungs and extremities (fluid retention), weight,
- glucose levels q6h or as ordered and lab work parameters,
- IV/CVAD site,
- infection: fever (VS), increased WBC’s and malaise -(triglycerides if getting fat emulsions)
- lytes, HCo3 etc in labs and assess for muscle cramps etc if imbalanced
- proteins: albumin, transferrin, prealbumin
maybe not daily but assess renal and hepatic fx too
can you infuse TPN by gravity?
no. use a pump always
your intervention when Your client is showing signs of weight gain, peripheral edema, crackles in lungs and I&O imbalance.
3 – rate likely needs to be slowed, solution may require titration (by doctor’s order)
How often should the tubing be changed with a peripheral IV receiving TPN with lipids?
q24h
with kids it is 12h. fr kids the lipids are gen infused separately. my instructor says that the lipids when given separately gen infuse in 12h anyway
Name 3 medications that are compatible with TPN solutions.
Insulin,
Vitamin B12 and
Ranitidine
– Ranitidine and Vitamin B12 is added for some pts but if the pt requires insulin it’s usually administered either SC for IV
What should you watch for should TPN be discontinued abruptly?
Patient may become hypoglycemic.
They have a lg amount of sugars in the TPN and then when suddenly withdrawn they will have excess insulin in their blood that will lower their BG too much because they no longer have the glucose fom TPN
what do you do if pt must be disconnected from TPN for a diagnostic etc
D10w is what you hang when the pt is going to go to xray or something nad cant have the TPN follow them. You need to conitnue the sugars
What are the main indications for why a client maybe receiving TPN?
Non-functioning GI tract (some types of major bowel surgery, paralytic ileus, bowel obstruction, small bowel obstruction, short bowel syndrome, trauma, severe malabsorption, intolerance to enteral feeds, chemo, radiation, bone marrow transplant)
- Extended bowel rest (enterocutaneous fistula, IBD exacerbation, severe diarrhea, moderate to severe pancreatitis)
Pre-operative TPN (pre-op bowel rest, severe malnutrition due to comorbities with non-functional GI tract, severely catabolic (protein breakdown leading to acidosis) patients when GI tract non-usable for more than 4-5 days.
Hypergravida emesis
what are long term indications for parental nutrition
- short bowel sydrome
- dysmotility syndrome
- radiation enteritis
- permanent bowel obstr from tumor
Most common complications related to TPN are:
what is most common?
infection most common -sludge accumulating in gallbladdercholecystitis -Liver disease—long term -Metabolic bone disease—long term -Allergy -Catheter related sepsis or bacteremia -Hyper/hypo glycemia an uncommon complication is refeeeding syndrome (if the pt is vry malnourishes
what is refeeding syndrome
my understanding is that when the malnourished pt receives too much PN too quick their BG raises and lots of insulin is released which stimulates glycogen, fat, and protein synthesis. Insulin causes K to enter cells. Cellular processes requires lots of phosphate, potassium, and magnesium and leads to depletion of the lytes as they shift intracellularly. Hypophosphatemia is the hallmark
i dont think we need to now this detail but i never quite got it before!
how is dextrose for peripheral veins
it is hard on them d/t high osmolarity
why should a renal or cardiac pt preferrably have TPN by central line
CVCs: it is a smaller volume with more concentrated calories
TPN can be administered through a peripheral IV as long as the solution is appropriate.
what is the consideration
Solutions containing less than 10% dextrose and are less calorically dense
. Blood glucose levels are very important to maintain in clients on TPN. Why?
High glucose levels are associated with cardiovascular events, general infection, systemic sepsis, acute renal failure and death
cards from notes now:
• Well nourished adults can be maint on periph IV (not TPN) up to _____ without difficulty
2 weeks
what is TPN and its advantage over eating
- The administration of totally digested vitamins, minerals, amino acids, dextrose, fat etc. directly into the circulatory system. The advantage is that it gets essential nutrients into a person who is unable to absorb through the GI tract.
Do you see people in hospital being started on TPN after 3 days of being NPO? Should they be?
P&P: when PN is the only nutritonal therapy for critically il pt, a pt who was healthy and well nourished before the illness can wait 7 days before initiation
pts should be started on it earlier rather than too late
what is the nutritional composition of TPN
Carbs (10 – 70% Dextrose) Amino acids (protein/nitrogen) Fats (fatty acids) Electrolytes Vitamins Trace elements (zinc, copper, manganese chromium etc.)
if giving TPN with lipids in it what must you consider when setting it up
use a larger filter. it prevents particulate matter or lg dropets from reaching a pt which could result in PE
Why don’t the fats/oils in TPN cause fat emboli? Is this a danger
No, it’s not a danger because the solution includes digestive enzymes – the same as if they were swallowed!
how is TPN usually given
centrally if soln is >10% dextrose but it can be given peripherally if it is 10% or less
potential complications of TPN from central line insertion and infusion
pneumothorax from insertion air embolism localized infect catheter related sepsis or bacteremia hyperglycemia hypoglycemia nutrition/lyte etc imbalance from improper TPB
actions for pneumothorax on insertion
- per HCP order remove the catheter
- oxygen
- chest tube
air embolism actions for
- clamp catheter
- L trendelenburg
- call HCP
- oxygen
if tunnel of pts CVC is infected what to do
remove after calling HCP
what to do if exit site of CVC is infected
call HCP and put warmcompress, daily site care, oral antibiotics
what do if pt hyperglycemic
call HCP
dr may order to slow infusion rate
actions if pt show signs of hypoglycemia
call
if PN d/c abruptly may need to restart D10W at previous rate
if pt has oral intake give 0.5 cup fruit juice and perform blood glucose monitoring; retest in 15-30min
is fat emulsion a major caloric source in periph or central
periph
central uses dextrose more
how many calories does periph vs central PN gen have
periph gen 1800 calories or less
central-2000 calories or mroe
considerations for giving PN to kids
ther vessels are v small-periph is a risk!
kids have less fluid in cells to begin with and are at risk of dehydration
your pt is at risk of refeeding syndrome what might dr order
lytes 2-3x daily
what is the advantage to having lipid emulsions in the PN soln directly
what is it called when the lipid emulsion is added to PN
dec risk of hypertriglyceridemia from rapid infusion
called 3 in 1 or 3:1 total nutrition admixture
what is pt at risk of if they dont have lipids in their PN within 3 wks and no PO intake
EFAD essential fatty acid deficiency
should you give TPN directly from fridge
no. let come to room temp for an hour
what to assess TPN for and what to check before skill
o label of PPN bag and lipid emulsion bottle w Mar; check additive and expiry, pt name
o examine lipid soln for separation of emulsion into layers,froth etc
check compatability of meds
how to do skill of giving TPN through central line
o Check soln and right label then compare label of bag to MAR, expirty date, pt name
o Check 2:1 for particulate matter and 3:1 for separation of soln
o Id pt
o Gloves and put filter on tubing. Prime. Connect to port and label and open clamp to keep line open
o Put tubing in pump open clamp completely and re flow (often 40-60)
o only inc rate gradually as PN is hyperosmolar.
o If must be d/c suddenl hang infusion of 5\% dextrose in water at same infusion rate to prevent hypoglycaemia. PN should be infused in 24hrs
o Use line solely for PN, no sample or CVP
o Don’t interrupt PN infusion and don’t exceed ordered rate
o Change IV admin sets for CPN q24hrs and when suspected contamination
should you inc rate of infusion slowly
yes
can you ever catch up TP\N
never
can you use a PN line for blood samples, IV meds, CVP?
no
your pt wants to take a shower can you interrupt the PN
no. dont interrupt for transport, blood transfusion either
what is periph given PN better for:
correcting nutritional deficit or preventing malnutriton
prevneting malnutriitun
how long is periph given PN gen used for
short term, less than 2 wks
skill of PN through periph line
o hygiene
o label of PPN bag and lipid emulsion bottle w Mar; check additive and expiry, pt name
o examine lipid soln for separation of emulsion into layers,froth etc
o ID pt and take vitals
o Gloves. Prep IV tubing for PPN soln; run soln through tubin to remove air. Turn clamp to off and cap tubing. Same procedure for separate lipid set.
o Connect PPN soln to pts fx periph IV. Dc old PPN tubing from IV site and insert adapter of new PPN infusion tubing. Open roller clam on new tubing. Allow soln to run to ensure that tubing is patent then reg IV drip rate
o Clean periph line tubing port and insert valve at end of fat emulsion tubing into injection port of main IV cloest to pt but below infusion filter on main parenteral nutrition line and label tubing
o Open clamp on fat line and chack flow rate. Infuse lipids initially at 1ml/min for adults and 0.1ml/min for kid for first 15-30min, inc rate as ordered
o Begin PPN at ordered rate. 20% fats are infused over at least 8hrs. All lipids can hang for 12hrs as separate infusion (review ppt says lipids in periph line can hang 24hrs)
when initially starting pt on PN how often do you take VS
what else do you assess
q10min for 30min
o Monitor flow rate hourly or more
o Labs daily and BG as ordered. Meas serum lipids 4hrs after dc infusion
o Monitor T q4h and regularly inspect site
o Wt, i/o, edema, breath sounds
what would s/s of intolerance to fat emulsion be and what would you do
o If intolerance to fat emulsion (as shown by inc triglycerides, inc T, chills, flushing, headache N, V, diaphoresis, muscle ache, chest and back pin, dyspnea, pressure over eyes and vertigo
o Turn PPN off, notify, prep to treat anaphylactic rxn according to dr orders, record lipid allergy
why is it easy for dehydration to occur when on PN
there is higher than normal glucose and hte kidney try to elim it with water following
now stuff from VIHA order sheets not sure if important?
what to hang at what rate if TPN not avail
D10W at 50ml/h
its 10:30am and the pts TPN orders arent changing, do you need to do anything
yes, send white and canary copies of TPN adult order form to pharmacy, keeping pink copy in chart. This is done for “same” or d/cd orders (they must be sent to pharmacy by 11
what is deadline that new or changed TPN orders must be received by
12
what is the lab draw schedule when starting TPN initially
daily x2 (meas tons of stuff) mon and thurs (diff stuff each day)
if pt has sensitive K levels that might be ordered daily
how often should pt be weighed
mon and thurs
what should be discontinued unless otherwise ordered when starting TPn
the pts continuous IV
our teacher said to know the s/s of imbal lytes
s/s of hypomagnesemia and hypermagnesemia
very rare, esp hypermagnesemia. the following are for both although it could be divided up more i guess
Muscular weakness
Tremors
Seizure
Paresthesias
Tetany
Positive Chvostek sign and Trousseau sign
Vertical and horizontal nystagmus
hypokalemia
hypocalcemia
heart rhythm irregularities
BP changes
s/s of hypernatremia
-those of dehydration eg oliguria, dry skin, tachy
-alt LOC d/t neuronal cell shrinkage: confusion, Lethargy, obtundation, abnormal speech, irritability, seizures, nystagmus, myoclonic jerks
-wt loss
general weakness
s/s of hyponatremia
Nausea and vomiting
Headache
Confusion
Loss of energy and fatigue
Restlessness and irritability
Muscle weakness, spasms or cramps
Seizures
Comas/s of hyperkalemia
fatigue or weakness
a feeling of numbness or tingling
nausea or vomiting
problems breathing
chest pain
palpitations or skipped heartbeatss/s of hypokalemia
often no symptoms
Weakness, tiredness, or cramping in arm or leg muscles
Tingling or numbness
Nausea or vomiting
Abdominal cramping, bloating
Constipation
Palpitations
Passing large amounts of urine or feeling thirsty most of the time
Fainting due to low blood pressure
Abnormal psychological behavior: depression, psychosis, delirium, confusion, or hallucinations.
can you check and hang a bag independently
no you need another nurse to check the bag
what is metabolic bone disease and how might long-term TPN cause it
it is either osteoporosis or osteomalacia (abn bone growth thats faulty…somehow ha)
it used to happen from the kind of amino acids they would put in the soln-> aluminum buildup.
Basically, if its formulated slightly wrong the calcium leaches out of the bones or another part of bone health is affected and you get metb bone disease!
much less common now :)
if you can only use peripheral IV for TPN what must be in the drs order
it must specify that it is peripheral so that the pharmacists prep it with more fluid etc
somehow the TPN for your pt wont be available for 4hrs. what do you do?
Hang D10w at 50ml/h and call the dr
meas of what indicates if GI function is returning and fluid status
2
intake and output
wt
wt gain greater than____ indicates fluid retention
> 1lb a day
which would be more likely to have soln separate 2:1 or 3:1
which would be ore likely to have particulate matter form
3: 1 has the lipid emulsion whcih might separate and
2: 1 more likely to have particulate
pt has hypermetabolic condition are they good candidate for peripheral TPN
no
why are lipids the primary source of calories in eripheral TPN and how is the protein content often different in peripheral vs central
lipids dont affect osmolarity as much, therefore easier on small periph veins
proteins alter osmolarity as dextrose does so they might include less protein in periph soln
who would be more at risk of hypertriglyceridemia pt on central or periph TPN
probably peripheral??
how should lipids hung by piggyback on periph IV flow rate be
p and p suggests starting a very slow infusion to let you watch for allergic rxn for first 15-30 mins. inc rate as ordered
if you have 20% fats infusiing by piggybacked periph IV how many hours must it run over minimum. max hrs for lipids to hang
min 8hrs
max 12hrs
how long afterd/c infusion should you measure lipids and why
minimum 4hrs or else the infusion will affect results
how to do nutrition assessment (from Jarvis pg 198…)
-wt and wt history
-routine labs
-diet (maybe from food diary or get them to recall)
-eating pattern
-change in appetite
-recent sx, trauma, burns, infect
-chronic illness
-NVD or constipation
-food allergies or intolerances
-meds or nutritional supplements or both
-self care behaviours
alcohol or illegal drug use
-exercise
objective
- BMI
- skin hair, lips eyes tongue gums nails msksltl neuro
what is more sensitive measure of nutrtional status albumin or prealbumin
prealbumin has shorter half life of 48hrs and thus is more sensitive
